In the era of COVID-19

Over the last three months, there have been globally radical changes concerning a pandemic following an outbreak of pneumonia. The origin of this viral outbreak of COVID-19 is unknown, but since the 31st of December, when the first case was reported in China, it has cost the lives of thousands of people around the world with the number of cases around the globe reaching several millions. These data reflect the number of people that have been tested positive than the actual number of patient carriers, and it is subject to unfortunate minute by minute changes.

World Health Organization has announced a name for this disease after identifying the underlying virus as part of the coronavirus team. The name Severe acute Respiratory Syndrome Coronavirus 2 or Coranvirus Disease 2019 (COVID-19) was declared by WHO in February 2020.
To our knowledge, no pharmaceutical product has shown its efficacy and safety against COVID -19. Different agents are under trial with no definite results yet. As in cases of infectious diseases, health systems and healthcare providers are forced to handle a load of cases with higher capacity and different distribution than usual. In addition to that, societies respond differently to contagious diseases while trying to adhere to the magic bullet theory.

We are not familiarized with epidemics that potentially might cause the lives of hundreds of thousands of people since that has not been the fact over the last fifty years. However, realizing the number of physicians that are exposed to the causative virus and the victims, among them, strict measures of personal protection have been implemented.
These measures respond mostly to acute pathology and respiratory distress, managing hypoxia, cardiogenic and septic shock hypotension, and ARDS. However, an algorithm for surgical prevention of disease spread and surgeons prophylaxis is not well established. Surgeons seem to underestimate the hazards of this situation while knowing that COVID -19 can render people contagious before having symptoms, thus exposing surgeons, anesthetists, surgical staff, other patients to the virus. History in a Crisis — Lessons for COVID-19 David S. Jones, M.D., Ph.D. NEJM

Given what governments seem to offer as far as screening testing for COVID is concerned, we cannot rely upon testing for every surgical candidate. More strict implementations should be made in order to mitigate the number of new cases and minimize the risk of surgeons being exposed to COVID – 19.
Efforts are made towards adequate staffing of healthcare systems in each country, tracing of all carriers, increase in productivity and availability of COVID-19 test, funding, and reinforcement of institutions with isolation chambers and dedicated COVID-19 areas in order to reduce morbidity from the disease

COVID-19 is a virus introduced to humans for the first time. It is very contagious since its basic reproduction number (R0) ranges from 2.24 to 3.58, and is significantly larger than 1.Common flu has an R0 of 1.3. Int J Infect Dis. 2020 Mar;92:214-217. doi: 10.1016/j.ijid.2020.01.050. Epub 2020 the 30th of January. Preliminary estimation of the basic reproduction number of novel coronavirus (2019-nCoV) in China, from 2019 to 2020: A data-driven analysis in the early phase of the outbreak.

Based on MERS –Cov CDC has suggested that symptoms may appear 2-14 days after exposure. The most common symptoms are related to fever, dry cough, fatigue, and shortness of breath. Other associated symptoms might be related to GI disorders, nausea, vomiting, muscle aches, and sore throat.
The median age of incidence is within the range of 49 to 59 years old. Most patients will not have severe symptoms. Comorbidities such as hypertension, diabetes, cancer, respiratory system disease, cardiovascular disease may link to the pathogenesis of COVID-19 and the severity of the symptoms it causes. The SARS-CoV-2 outbreak: what we know Di Wu Tiantian Wu Qun LiuZhicong Yang

Mortality is higher in patients older than 60 years old. Patients tend to have lower lymphocytes, albumin, and serum sodium levels and more elevated total bilirubin, CRP, CK, and lactate dehydrogenase, especially those presenting with imaging findings. Epidemiological, clinical characteristics of cases of SARS-CoV-2 infection with abnormal imaging findings Xiaoli Zhang 1, 2 Huan Cai 1, 2 Jianhua Hu 1, 2 Jifang Sheng Lanjuan Li
Physicians should be aware not to underestimate other emergency cases that will keep on happening according to their prevalence before the viral outbreak

At the same time, distinguishing between different types of pneumonia and COVID-19 induced one is a top priority. Same prioritization issues for non-infectious but inflammatory diseases that may cause the same symptoms. The latter ones resemble mostly to chronic illnesses that might have common aspects with pathology caused by an infection such as proinflammatory state and immunosuppression. COVID-19: consider cytokine storm syndromes and immunosuppression Puja Mehta Daniel F McAuley Michael Brown Emilie Sanchez Rachel S Tattersall Jessica J Manson

In order to rule out COVID-19 pneumonia WHO stresses out, we need to “ Test, test, test.” Virus isolation and viral nucleic acid detection is the gold standard for virus diagnosis Yu F, Du L, Ojcius DM, Pan C, Jiang S. Measures for diagnosing and treating infections by a novel coronavirus responsible for a pneumonia outbreak originating in Wuhan, China. Microbes Infect 2020; S1286-4579:30025-3 Higher rate of detection of lower respiratory infections requires a variety of specimens, mostly swabs from the nasopharynx or trachea extracts. Laboratory testing for coronavirus disease (COVID-19) in suspected human cases World Health Organisation the 19th of March 2020.

Meticulous evaluation and examination, according to COVID-19 criteria, should be performed before a patient ends up for pre-operative evaluation. Ideally, all or at least suspected for infection patients should undergo COVID-19 testing. As testing capacities of hospitals augment and testing is more rapid and affordable, most likely universal testing may be recommended. All patients should be treated as positive until proven otherwise.

The surgical care of gynecologic patients during the COVID-19 pandemic presents numerous challenges regarding not only patient and community safety, but that of the physicians and operating room personnel. Guidance around minimally invasive gynecologic surgery is a rapidly evolving topic, and the information presented below is subject to change as new data becomes available. AAGL


Data accumulating will force changes as far as gynecologic surgery is concerned. Scientific organizations are unanimous upon their decisions to defer elective surgeries. By definition, all resources should be available for the fight against this pandemic. In addition to that, the reduction of blood donors and the high need in plod transfusion during the epidemic indicates that no blood units should be used in operations that can be postponed safely. Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – sixth update the 12th of March 2020

In symptomatic patients, it is universally accepted that if surgery is not urgent, wait for the symptoms to resolve before proceeding to surgery.
Patient and staff safety go side by side with viral spread and adaptation of new personnel protective measures. All guidelines are subject to daily updates. They will follow changes in testing criteria and capacity of institutions being able to process more significant numbers of these tests. However, we need to keep in mind staffing challenges that might occur down the road since COVID -19 patients’ numbers will likely grow, and hospital resources will strain. Defining that, healthcare employees treating COVID – 19 positive patients need to take all the preventive measures to stay on the safe side.

BGCS Inpatient and outpatient considerations include means that minimize patient trafficking towards the hospital. These include education of patients to adopt social distancing, restrict visitors to all inpatients or for patients to attend clinics alone, reduce traffic in hospital wards and opt for the surgical intervention that will offer higher chances of shorter hospital stay and complications.

Essential training of all personnel about Personal Protection Equipment (PPE) is mandatory. Training should prevent disease spread and contamination during the wearing and removal of PPE’s. The movement of personnel in and out of the operating room should be limited.
Personal Protective Equipment (PPE) for Operating Room Personnel:
PPE’s include disposable surgical cap, gloves, shoe covers, eye protection, and gowns. The debate between the efficacy of conventional surgical and N-95 masks might end in the depletion of vital resources. The COVID-19 virions are 50-200 nm in size. At the same time, N-95 masks are rated to filter, with 95% efficiency, particles that are greater than 300 nm in size Chen N, Zhou M. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–513.

Conventional surgical masks may provide a similar level of protection as the N95 mask in general-use conditions Radonovich LJ, Simberkoff MS, Bessesen MT, et al. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019;322(9):824–833. doi:10.1001/jama.2019.11645

Dr. Plevris

Minimally Invasive Gynecologic / Robotic Surgery

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